St. Joseph s Continuing Care Centre March 2012 St. Joseph s Continuing Care Centre 1
Part A: Overview of Our Hospital s Quality Improvement Plan 1. Overview of our quality improvement plan for 2012-13 The focus of our plan is patient safety, patient experience and patient flow which speak to our mission, vision and values. St. Joseph s Continuing Care Centre includes 50 Complex Continuing Care beds operated under the Public Hospitals Act and 150 Long-Term Care beds operated under the Long-Term Care Act, 2007. In addition, we currently operate 40 Transitional Care Beds under a Restorative Care model in partnership with Cornwall Community Hospital and the Champlain CCAC. The beds are funded through the AAH program with a goal to reduce ALC pressures in our community. 2. What we will be focusing on and how these objectives will be achieved We will be focusing on four quality dimensions in this plan; namely safety, effectiveness, patientcentred and integration. In the area of safety our objective is to reduce the use of physical restraints. Our percentage in this indicator is significantly higher than the both the LHIN and provincial average. In order to achieve this we plan to establish a multi-disciplinary team to review current restraint policy in relation to best practice and reassess all patients for restraint use in conjunction with policy. The team will also consult with other CCC providers in order to develop procedure. Our effectiveness focus will be the continuation of sound financial practice in order to maintain a positive total margin and ultimately eliminate the accumulated deficit position (unrestricted net asset deficiency) of the hospital. The hospital inherited a significant deficit, in excess of $1 million, in 2004 at the time of hospital restructuring and has worked diligently to reduce this over time. Our patient-centred objective is to increase the participation rate in patient satisfaction surveys and to expand the scope of patient satisfaction survey process to include our 40 Transitional Care beds. In the past, the patient satisfaction survey was done annually capturing information from in-patients at a point in time. As we move towards the delivery of more transitional care programs we will be implementing a survey upon discharge for transitional care patients and implementing a process whereby the survey for long-term complex care patients will be initiated at the time of their annual review. We expect that this new process model will allow us to capture more information and facilitate trend analysis and more timely response to identified issues. To address the integration dimension we are focusing on reducing the ALC days in our hospital operation in order to create more capacity to provide transitional care programming and achieve better patient flow. St. Joseph s Continuing Care Centre 2
3. How the plan aligns with the other planning processes The objectives of our plan align with several other collaborative planning processes and initiatives that are currently underway. With respect to our safety objective; there is alignment with organizational practices required in our Long-Term Care operation with respect to minimal restraint. The effectiveness objective to improve financial results is consistent with the HSAA planning process requirements and the financial performance indicators included in our accountability agreement. The integration objective aligns with the organizations planning process for CCC moving forward. In the Action Plan Report from Dr. David Walker one identified need for the Champlain LHIN was to stop co-horting of ALC-LTC patients in CCC beds in order to create capacity. This objective is intended to address this recommendation. 4. Challenges, risks and mitigation strategies The challenges and risks which may impact on the success of our plan include availability of resources and response to unforeseeable situations. The impact of the new Patient-Based Funding for Hospitals, effective 01 April 2012, is not known at this time. Key assumptions in the plan development is the level of operational funding for the hospital for the planning period 2012-2013 will be equal to the 2011-2012 allocation and that AAH funding to operate the 8 Transitional Care beds will continue for 2012-2013. As with any plan, an unforeseeable event such as outbreak, could negatively impact availability of health human resource and reduce system capacity and create a financial burden for the hospital. St. Joseph s Continuing Care Centre 3
Part B: Our Improvement Targets and Initiatives St. Joseph s Continuing Care Centre 4
Part C: The Link to Performance-based Compensation of Our Executives Manner in and extent to which compensation of our executives is tied to achievement of targets The Hospital has only one executive position; namely the Executive Director. For fiscal year 2013 five percent (5%) of annual base salary of the Executive Director will be linked to the achievement of 100% of the targets set out in our QIP. Achievement of all targets would result in 100% payout; partial achievement of targets will result in partial payout, as determined by the Board of Directors. Part D: Accountability Sign-off I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan: 1. Was developed with consideration of data from the patient relations process, patient and employee/provider surveys, aggregated critical incident data, and patient safety indicators; 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive compensation is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning. Richard Abell Board Chair John Robinson Quality Committee Chair Bonnie Ruest Chief Executive Officer St. Joseph s Continuing Care Centre 5
Draft subject to review by the Board of Directors PART B: Improvement Targets and Initiatives 2012/13 St. Joseph's Continuing Care Centre Please do not edit or modify provided text in Columns A, B & C AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current performance Target for 2012/13 Target justification Priority level Planned improvement initiatives (Change Ideas) Methods and process measures Safety Reduce use of physical restraints Physical Restraints: The number of patients who are physically restrained at least once in the 3 55% 45% moving toward 1 1) establish multi-disciplinary CCRS quarterly days prior to initial assessment divided by all cases with a full admission assessment - Q4 FY LHIN average 2) consult with other CCC providers in 2009/10 - Q3 FY 2010/11, OMHRS Effectiveness Improve organizational financial health Total Margin (consolidated): Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year. Q3 2011/12, OHRS 0.38% 0.20% HSAA 3 1) 2) N) Patient-centred Increase participation rate in patient satisfaction survey In-house survey (if available): the Hospital will develop and implement a discharge survey for patients from Transitional Care programs; e.g. Restorative Care and Assess and Restore. Data from survey process will be used to recommend improvements in programme delivery. 30% 70% 2 N) Goal for change ideas (2012/13) Comments Integrated Reduce percentage ALC Bed Days ALC days in CCC beds 12% 9% Results of best 2 1) in CCC beds performers 2) N)